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ARDS (II)
Principal Investigator: Dr Brian Cuthbertson Inhaled nitric oxide and prone positioning in Acute Lung Injury and Acute Respiratory Distress Syndrome
Current
State: Complete (23.2.04; Up-date 23.2.06
Inhaled nitric oxide and prone positioning in Acute Lung Injury and Acute Respiratory Distress Syndrome
Brian H Cuthbertson on behalf of the SICS EBM group Senior Lecturer in Anaesthesia & Intensive Care, Institute of Medical Sciences, University of Aberdeen, Forresterhill, Aberdeen, AB25 2ZD. Correspondence: b.h.cuthbertson@abdn.ac.uk SICS EBMG web site June 2004 Background: Acute hypoxaemia and pulmonary artery hypertension are thought to be factors that relate to poor outcome in ALI / ARDS. ARDS has a 30-60% mortality in differing series and around 20-40% of patients who die with ARDS are said to die from acute severe respiratory failure. The rest die from multi-organ system failure. It was believed that measures that improved oxygenation and pulmonary mechanics would improve outcome in ALI / ARDS. Objectives: To critically appraise the evidence for inhaled NO and prone positioning in ALI and ARDS and make an evidence-based practice recommendation. Search strategy: ARDS with subheadings- therapy / drug therapy limited to prospective randomised trials or double blind method; human; AIM journals. Selection criteria: One reviewer (BHC) selected studies for inclusion. One reviewer (BHC) assessed trial quality and independently extracted the data and two others (CC and MH) independently checked the analysis. Data collection and analysis: Five randomised controlled trials involving 688 patients were included. There were sufficient data to enable conclusions to be drawn from the 5 randomised trials. Two of these studies were randomised controlled studies of prone positioning in ARDS and the other three were of inhaled NO therapy in ALI / ARDS. Only randomised controlled studies were used in final analysis. Main results: Gattinoni et al (1) showed no difference between prone and control groups in ALI / ARDS (RRR 16%, [CI -22% to 53%]) in a well designed study. Staudinger et al (2) only compared prone positioning with continuous rotational therapy. Lundin et al (3) showed no difference in outcome between conventional ventilation and conventional ventilation plus inhaled NO in ALI / ARDS (RRR -10%, [OR -46% to 26%]) but the study was not powered to detect mortality benefit as it was stopped early. It did suggest an improvement in oxygenation can be obtained. Dellinger et al (4) showed no outcome benefit from inhaled NO in ALI / ARDS (RRR 7%, [CI –40% to 54%]) but this was not designed as an outcome study. It did demonstrated appropriate safety and efficacy with improved oxygenation in majority of patients. Troncy et al (5) also failed to show an outcome benefit in ALI / ARDS (RRR –13%, [CI –179 to –54%]) but this study was also not powered for this outcome. Reviewers conclusions: Grade A recommendation: The use of inhaled NO and prone positioning in all-comers with ARDS in Scotland is not justified from current evidence base. Further research is required to explore a role of both therapies in ARDS associated with severe respiratory failure. Citations with links to CATs:
1. Gattinoni L. Tognoni G. Pesenti A. Taccone P. Mascheroni D. Labarta V. Malacrida R. Di Giulio P. Fumagalli R. Pelosi P. Brazzi L. Latini R. Prone-Supine Study Group. Effect of prone positioning on the survival of patients with acute respiratory failure. New England Journal of Medicine 2001; 345(8):568-73. CAT.
2. Staudinger T. Kofler J. Mullner M. Locker GJ. Laczika K. Knapp S. Losert H. Frass M. Comparison of prone positioning and continuous rotation of patients with adult respiratory distress syndrome: results of a pilot study. Critical Care Medicine 2001. 29(1):51-6. Abstract
3. Lundin S. Mang H. Smithies M. Stenqvist O. Frostell C. Inhalation of nitric oxide in acute lung injury: results of a European multicentre study. The European Study Group of Inhaled Nitric Oxide. Intensive Care Medicine 1999 25(9):911-9. CAT.
4. Dellinger RP. Zimmerman JL. Taylor RW. Straube RC. Hauser DL. Criner GJ. Davis K Jr. Hyers TM. Papadakos P. Effects of inhaled nitric oxide in patients with acute respiratory distress syndrome: results of a randomized phase II trial. Inhaled Nitric Oxide in ARDS Study Group. Critical Care Medicine 1998; 26(1):15-23. CAT.
5.
Troncy E. Collet JP. Shapiro S. Guimond JG. Blair L. Ducruet T.
Francoeur M. Charbonneau M. Blaise G. Inhaled nitric oxide in acute respiratory
distress syndrome: a pilot randomized controlled study. American Journal of
Respiratory & Critical Care Medicine. 1998;157(5 Pt 1):1483-8.
CAT. CC – Chris Cairns MH – Martin Hughes
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